OBJECTIVE:: To describe recent experience using the Texas Advance Directives Act to facilitate care of terminally ill children managed in the two tertiary pediatric hospitals of the Texas Medical Center, Houston, TX. DESIGN:: Retrospective chart review. SETTING:: Two multidisciplinary pediatric intensive care units in Houston, TX. PATIENTS:: Five terminally ill children whose parents were unable to acquiesce to comfort or palliative care. INTERVENTIONS:: Implementation of the Texas Advanced Directives Act of 1999. RESULTS:: Suspension of interventions thought to be medically inappropriate by the physicians of record in four of the five cases, with transfer of care in one instance. CONCLUSIONS:: Use of institutional policies in accordance with the Texas Advance Directives Act may assist in the care of terminally ill children and their families.